Every day I experience life in the world of healthcare IT, supporting 3000 doctors, 18000 faculty, and 3 million patients. In this blog I record my experiences with infrastructure, applications, policies, management, and governance as well as muse on such topics such as reducing our carbon footprint, standardizing data in healthcare, and living life to its fullest.

Wednesday, July 16, 2008

Open Source Medical Records

Last week, I had lunch with the CEO of MedSphere, Mike Doyle, to learn about the company's plans for OpenVista. The idea is simple - take the the publicly available code from the Veterans Administration clinical information system, add new modules such as revenue cycle interfaces that are needed in practices outside the VA system and include support/implementation services. In effect, you'll have the "Red Hat Linux" of the electronic health record world.

Medsphere has chosen to package Vista in two forms - Enterprise for large hospitals/integrated delivery systems needing departmental system and Clinic for small offices/multi-specialty clinics needing strong outpatient functionality. Enterprise includes

The VA's Vista system is well known for its integration, functionality and sophisticated decision support. I spoke with several for profit vendors about their opinion of an Open Source EHR based on Vista. They had a very reasonable response - the real cost of providing a comprehensive clinical IT solution is not really the code (since most vendor products development costs have already been recouped). The cost is in the service.

Medsphere's true measure of success will be its ability to deliver high touch support in a scalable way as its market expands. Mike shared the Medsphere core values, vision, value proposition with me (the picture above). You'll see that their ideology is very noble - reduce costs, improve quality, and make a difference in healthcare. Decoding the slide, BHAG means Big Hairy Audacious Goals from the Jim Collins article Building Your Company's Vision. The Hedgehog Concept refers to the understanding of the one thing you can be best at. Jim Collins discusses it in Good to Great based on Isaiah Berlin's essay “The Hedgehog and the Fox".

8 comments:

This is incredible. After learning that VA's source code was readily available to anyone interested, I knew a business based on it was soon to follow. To take it into the open source market is even more exciting and true to VA's ever-improving EHR mission.

I'm always exposed to the most amazing things through your blog. Thanks for the great postings!

The promise of open source is great, and the 50,000 foot view of OpenVista is inspiring. The low-level reality is that their technology stack is cobbled together like a Rube Goldberg contraption, from MUMPS to .NET/Mono to GTK to Java to Delphi to Cache/Fidelity GT.M (I'm citing the OpenVista brochure). Good luck finding developers outside the OpenVista team who are proficient with that stack, or even with just the MUMPS core it's all built around. The open source promise of "given enough eyeballs, all bugs are shallow" doesn't go very far with this particular codebase. No modern developer is going to invest in MUMPS except for an opportunistic few who don't mind "technology hospice" work.

“Service” is not just “customer service” but also includes “software as a service” and “remote-hosting service,” which the larger, established vendors may be more capable of delivering.

One additional thought, based on recent conversations triggered by Clay Shirky’s new book, Here Comes Everybody. The for-profit vendors have used profitability to be able to hire enough developers to create robust and innovative software. Some open source projects (like Linux or Apache) have managed to aggregate enough volunteer contributors to be equally robust and innovative, but many open source projects never reach that critical mass of developers. For small projects, this is not necessarily a problem because the end-user can simply “finish” the code himself, but for complex things like EMRs, long term innovation and product evolution will require lots (and lots) of developers. With open source EMR vendors, the ability to attract this critical mass of developers remains to be proven. Some CIOs would probably prefer the “safety” of a successful commercial vendor rather than an as-yet-unproven open source vendor. Of course, if an open source vendor does attract a large core of volunteers, then the argument comes back to who provides the best “service” – be it customer service or software-as-a-service.

Oran, your constant denigration of Mumps does not, I'm afraid, stand up to scrutiny. The very features you appear to detest so vehemently are, somewhat ironically, becoming the very features that the likes of Amazon, Google and the Apache folks are now designing into their internet-scale database technologies. See this blog for further background on this reality.

The fact is that Mumps is tried and tested and the healthcare products that have been built with it work well and have stood the test of time, all around the world. Indeed I'm not aware of one successful migration of these applications to "modern" technologies despite the best endeavours of some of the largest names in IT armed with sackloads of cash: our own UK NHS IT strategy being one such multi-billion pound embarassing example.

Modern developers are, in fact, investing in the very features that makes Mumps what it is. Perhaps the time has come for them to do the exact opposite of what you suggest, and invest in Mumps instead of the as yet unproven "new kids on the block".

Medsphere was once the leader in open source healthcare IT, but in 2006 they sued their CTO for (shock!) releasing code as open source.

The lawsuit was settled last December. When I was working with them in 2005 they had a huge lead over their rivals. I don't know where they sit now because I’m outside that industry, but they must have lost a lot of momentum and influence that will be difficult to regain.